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0 <br />' SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV1ROWENTAL HEALTH DIVISIO)I <br />' UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTA;CT <br /> NAME <br /> CF <br /> I v EELS , D Y <br /> I FACILITY ADDRESS S1 TE PHONE a with AREA CODE <br /> CODEF"Q <br /> 4C/ <br />' 1 CITY ` / STATE ZIP CODE <br /> a of TANKS <br /> a[ SITE <br /> A ADPL ANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I HAILING ADDRES �fO /�D i/ APPLICANT PHONE f! uITN AREA CODE <br /> 1 A �`-'pi� <br /> ,1 <br /> N CITY '{� SIATE ZVm,5 <br /> TYPE of APPLICATION <br /> T /{"Tf`'`/ CLOSURE, INSTALLATION, etc <br />' TOTAL <br /> A <br /> C 19861987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100 00 S <br /> NT COMOAR <br /> r rL.l� A 01000 RR."tfM <br /> i _ i r �v ttt� V" <br /> All <br /> t� f <br /> t✓'DAC�:,�l�tk`d ���� ��Yt/ I � �i �■� / ��_ ,44 <br /> +.I, ,I ' r <br /> al <br /> t4do6 U PAI oAwrvFCrdm�l l! cALIPoANIA C4i8! ,7 I;�y✓ w <br /> 70 <br /> T <br /> u PIAN CHECx FEE - S53 Ob per hour (8 hours minimtna per Facility) 5424 00 minimisn <br /> R REPAIR TANK T D U(s) <br /> 1 E <br /> P TAIIK REPAIR FEE = $53 00 per hour (3 hours minimum/TANrr 0 TANK(s) % SI59 00 = 5 <br /> A <br /> ! y - 5159 00) S <br /> R P!P[NG REPAIR REVIEW CONSTRUCTION = S53 00 per hour (3 hour minlmun per faclllt <br />' H CONSULTATIONS URAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br />' S <br /> C FEE = 153 00/hr FEE = 553 (10/hr FEE = S 53 00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> �..�.,...y.Y INN V 3..`<�[<a<.ri�k<i"N[[ry.!«[[�• Yv,d CASH I <br /> 1Eck i01S+J Y«V M' <i O T[!`.<a.a<♦,[[a'<e<L�•.Mn.1�.ua.y°^.�..r<....•.��—•�.�••��Y <br /> i, ,Til 'S rn"�n ns satil 'V&7 } TIySI�CCbE -F AlhN1T RCPT) [ JY CVV"8Y' E �} I <br /> R i <br /> x <br /> �«aeroal<oQ sse+�eaS�Scar eta F.aNS 1�Y ffi4L]13`��t":.A4�"""�.Y k"! `5^'J� Y N!` <'[Y•["�•" ,• SY••4>�r S.. [!f Y �1Y"J�..,1�c...+.,d ivyf}xM1i aes A\*laf NK lsaArr!MS JmM q�leu s1.lW Tell L'� <br /> ru •t nt> >ocv 12171A,vnl ft Pian 11 <br /> k 1) <br />